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Zhou L, Liu Y, Wen Z, Yang S, Li M, Zhu Q, Qiu S, Gao Y, Wang H, Yuan Y, Zhang H, Chen C, Zeng W, Guan Z, Pan X. Ruxolitinib combined with doxorubicin, etoposide, and dexamethasone for the treatment of the lymphoma-associated hemophagocytic syndrome. J Cancer Res Clin Oncol 2020; 146:3063-3074. [PMID: 32617699 DOI: 10.1007/s00432-020-03301-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/22/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Case reports suggest that ruxolitinib-containing treatment could increase the clinical response rate of patients with hemophagocytic syndrome (HPS). This study aimed to explore the effect of ruxolitinib-containing treatment for patients with lymphoma-associated hemophagocytic syndrome (LAHS). METHODS This was a retrospective study of patients with LAHS hospitalized at the First Affiliated Hospital of Guangdong Pharmaceutical University between October 2017 and September 2019. Patients were treated with HLH-94 (etoposide and dexamethasone) or R-DED regimen (ruxolitinib, doxorubicin, etoposide, and dexamethasone). The clinical characteristics, treatment responses, and overall survival (OS) were compared. The patients were divided into the HLH-94 group (n = 34) and the R-DED group (n = 36). RESULTS Compared with HLH-94, R-DED might effectively improve the clinical manifestations, including fever and splenomegaly in patients with LAHS, and control the systemic cytokine storm. The response rate at 2 weeks was 54.8% in the HLH-94 group, which was lower than in the R-DED group (83.3%) (p = 0.011). The OS was significantly prolonged in the R-DED group compared with the HLH-94 group (median, 5 vs. 1.5 months, p = 0.003). The multivariable analysis showed that lower IL-10 levels [hazard ratio (HR)] = 1.000, [95% confidence interval (CI)] 1.000-1.000, p = 0.012), R-DED regimen (HR = 0.196, 95% CI 0.084-0.457, p < 0.001), and non-NK/T-cell lymphoma (HR = 0.254, 95% CI 0.102-0.628, p = 0.003) were associated with better OS. The prognosis of patients with LAHS was generally poor. CONCLUSION Ruxolitinib can be combined with chemotherapy in HPS. It is feasible, with no early signals of increased toxicity.
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Affiliation(s)
- Lanlan Zhou
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Yanan Liu
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Zhenzhen Wen
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Shimei Yang
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Mingjie Li
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Qiuhua Zhu
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Shiqiu Qiu
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Yanmin Gao
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Hong Wang
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Yuemei Yuan
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Hanling Zhang
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Chaolun Chen
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Wenbin Zeng
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Zebing Guan
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Xueyi Pan
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China.
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Three Consecutive Cases of Familial Hemophagocytic Lymphohistiocytosis, Including a Case Due to Maternal Uniparental Disomy. J Pediatr Hematol Oncol 2020; 42:e819-e821. [PMID: 31789783 DOI: 10.1097/mph.0000000000001681] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We have experienced 3 consecutive cases of familial hemophagocytic lymphohistiocytosis (FHL). All affected infants had mutations in exon 3 of the perforin gene. The first had a homozygous mutation, c.1168C>T (p.R390*), caused by maternal uniparental isodisomy. The second and third had compound heterozygous mutations: c.781G>A (p.E261K) and c.1491T>A (p.C497*); c.1724G>T (p.C242G) and p.R390*, respectively. FHL is very rare in Northern Japan but should be suspected if infants exhibit prolonged fever. This is the first report of a relationship of p.R390* with FHL caused by uniparental isodisomy, and the second reported case of FHL type 2 with this form of inheritance.
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Quan C, Li C, Ma H, Li Y, Zhang H. Immunopathogenesis of Coronavirus-Induced Acute Respiratory Distress Syndrome (ARDS): Potential Infection-Associated Hemophagocytic Lymphohistiocytosis. Clin Microbiol Rev 2020; 34:e00074-20. [PMID: 33055229 PMCID: PMC7566897 DOI: 10.1128/cmr.00074-20] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The outbreak of coronavirus disease 2019 (COVID-19) in December 2019 in Wuhan, China, introduced the third highly pathogenic coronavirus into humans in the 21st century. Scientific advance after the severe acute respiratory syndrome coronavirus (SARS-CoV) epidemic and Middle East respiratory syndrome coronavirus (MERS-CoV) emergence enabled clinicians to understand the epidemiology and pathophysiology of SARS-CoV-2. In this review, we summarize and discuss the epidemiology, clinical features, and virology of and host immune responses to SARS-CoV, MERS-CoV, and SARS-CoV-2 and the pathogenesis of coronavirus-induced acute respiratory distress syndrome (ARDS). We especially highlight that highly pathogenic coronaviruses might cause infection-associated hemophagocytic lymphohistiocytosis, which is involved in the immunopathogenesis of human coronavirus-induced ARDS, and also discuss the potential implication of hemophagocytic lymphohistiocytosis therapeutics for combating severe coronavirus infection.
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Affiliation(s)
- Chao Quan
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha City, Hunan Province, China
- Sepsis Translational Medicine Key Lab of Hunan Province, Central South University, Changsha City, Hunan Province, China
| | - Caiyan Li
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha City, Hunan Province, China
- Sepsis Translational Medicine Key Lab of Hunan Province, Central South University, Changsha City, Hunan Province, China
| | - Han Ma
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha City, Hunan Province, China
- Sepsis Translational Medicine Key Lab of Hunan Province, Central South University, Changsha City, Hunan Province, China
| | - Yisha Li
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
| | - Huali Zhang
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha City, Hunan Province, China
- Sepsis Translational Medicine Key Lab of Hunan Province, Central South University, Changsha City, Hunan Province, China
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Different Clinical Presentation of 3 Children With Familial Hemophagocytic Lymphohistiocytosis With 2 Novel Mutations. J Pediatr Hematol Oncol 2020; 42:e627-e629. [PMID: 31651726 DOI: 10.1097/mph.0000000000001589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Although familial hemophagocytic lymphohistiocytosis (FHL) generally manifest with a combination of unremitting fever, hepatosplenomegaly, and pancytopenia; unusual presentations should also be taken into account. Herein, we present 3 FHL cases with 2 novel mutations with different initial presentations. The first patient bearing a homozygous truncation mutation in UNC13D (c.2650C>T.p.Gln884Ter) presented with central nervous system involvement and skin rash. The patient responded to the HLH-2004 protocol, and allogenic hematopoietic stem cell transplantation was performed from her healthy sister. The second and third patients with homozygous splice site mutation (c.430-1G>A) in STXBP2 were siblings who presented at birth with fevers, elevated aspartate aminotransferase, alanine aminotransferase, and hyperferritinemia but did not fulfill FHL criteria. The last 2 infants died despite intervention. Hematologists should be vigilant about the different presentation of FHL in children.
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Santana Quintana A, Valga F, Vega Díaz N, Fernández JM, Quevedo Reina JC, Rincón Tirado M, Aladro Escribano S, Rodríguez Pérez JC. [Not all cytokin storms are due to COVID-19: Hemophagotic syndrome with renal involvement secondary to extranasal lymphoma and Epstein-Barr virus. A case report during the pandemic]. Nefrologia 2020; 41:347-349. [PMID: 33069494 PMCID: PMC7492003 DOI: 10.1016/j.nefro.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Adonay Santana Quintana
- Servicio de Nefrología. Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, España.
| | - Francisco Valga
- Servicio de Nefrología. Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, España
| | - Nicanor Vega Díaz
- Servicio de Nefrología. Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, España
| | - Juan Manuel Fernández
- Servicio de Nefrología. Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, España
| | - Juan Carlos Quevedo Reina
- Servicio de Nefrología. Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, España
| | - Marian Rincón Tirado
- Servicio de Nefrología. Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, España
| | - Sara Aladro Escribano
- Servicio de Nefrología. Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, España
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Chango Azanza JJ, Lopetegui Lia N, Calle Sarmiento PM. Bile Cast Nephropathy Secondary to Hemophagocytic Lymphohistiocytosis With Liver Failure. Cureus 2020; 12:e10226. [PMID: 33042669 PMCID: PMC7535873 DOI: 10.7759/cureus.10226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication seen in patients with hemophagocytic lymphohistiocytosis (HLH). More than half of patients with HLH require renal replacement therapy (RRT). There are four main causes of kidney dysfunction in HLH, which include acute tubular necrosis (ATN), hypoperfusion, tumor lysis syndrome (TLS), and HLH-related glomerulopathies. Bile cast nephropathy (BCN) is a known cause of kidney injury in patients with liver failure and hyperbilirubinemia. We present the case of a 58-year-old man who presented to the hospital with painless jaundice, choluria, acholia, and generalized malaise and was found to have hyperbilirubinemia and kidney injury in the setting of HLH, who underwent a renal biopsy showing bile salt casts with degenerating tubular lining cells consistent with BCN. This case highlights the importance of considering BCN as a cause of kidney injury when a patient with HLH presents with liver failure and elevated bilirubin levels.
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Affiliation(s)
| | - Nerea Lopetegui Lia
- Internal Medicine, University of Connecticut School of Medicine, Farmington, USA
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[Clinical study of haploidentical hematopoietic stem cell transplantation on 15 cases of adult-onset primary hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:511-516. [PMID: 32654467 PMCID: PMC7378280 DOI: 10.3760/cma.j.issn.0253-2727.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: This study was designed to evaluate the efficacy of haploidentical hematopoietic stem cell transplantation (haplo-HSCT) for adult-onset primary hemophagocytic lymphohistiocytosis (HLH) . Method: A retrospective study was carried out to analyze the clinical data of 15 adult patients with primary HLH who received haplo-HSCT from January 2013 to October 2019 in Beijing Friendship Hospital, Capital Medical University, Beijing, China. Results: Among the 15 patients included in the study, ten were males and five were females, with a median age of 21 years old (18-52) . Eight of the patients had familial hemophagocytic lymphohistiocytosis type 2 (FHL-2) , four had FHL-3, one had Griscelli syndrome type 2 (GS-2) , one had X-linked lymphoproliferative disease type 1 (XLP-1) , and the other had XLP-2. The median time from HLH diagnosis to transplantation was 7 months (2-46 months) . Seven patients were treated with Bu/Cy condition regimen prior to transplantation. Meanwhile, the other eight cases were treated with TBI/Cy. The median concentration of mononuclear cell (MNC) infusion was 12.6 (9.2-20.3) ×10(8)/kg and CD34(+) cells was 4.91 (2.51-8.37) ×10(6)/kg. The median time of leukocyte engraftment was on day 13 following transplantation (10-23 days) , and the platelet engraftment was on day 12 (9-36) . Graft failure (GF) finally occurred in two patients (one primary GF and one secondary GF) . The cumulative incidence of acute graft-versus-host-disease (GVHD) grades 2 to 4 was 71.4% (10/14) and chronic GVHD was 30.8% (4/13) , respectively. The five-year overall survival (OS) for all 15 cases of primary HLH was 65.5% (95% CI, 34.9%-73.3%) and the transplant-related mortality (TRM) was 26.7% (4/15) . The five-year OS was 87.5% (95% CI, 38.7%-66.3%) in eight patients who received haplo-HSCT subsequent to initial therapy and 42.9% (95% CI, 8.5%-65.2%) in patients seven patients who needed salvage therapy prior to haplo-HSCT (χ(2)=2.387, P=0.122) . The five-year OS was 85.7% (95% CI, 50.4%-89.8%) in eight patients who achieved complete response before haplo-HSCT and 42.9% (95% CI, 6.4%-53.0%) in seven patients with partial response (χ(2)=3.185, P=0.074) . Conclusion: The results indicated that haplo-HSCT is a promising method for the treatment of primary HLH in adults.
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108
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Agudelo Higuita NI, Yuen C. Hemophagocytic Lymphohistiocytosis Secondary to Ehrlichia Chaffeensis in Adults: A Case Series From Oklahoma. Am J Med Sci 2020; 361:269-273. [PMID: 32928497 DOI: 10.1016/j.amjms.2020.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 08/05/2020] [Accepted: 08/26/2020] [Indexed: 11/16/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation that occurs as either a familial disorder or as a sporadic condition in association with a variety of triggers. Infections are the most common cause of HLH in adults and should be searched for as early treatment usually results in a favorable outcome. Human monocytotropic ehrlichiosis (HME) is a very rare cause of HLH. Failure to consider ehrlichiosis can result in misdiagnosis and an increased length of hospitalization and healthcare cost as described in our report. Treatment for secondary HLH is aimed at reducing hypercytokinemia and eradicating inflammatory and infected cells. It is important to promptly initiate doxycycline when tick-borne diseases are being entertained as a possible trigger, as the antibiotic is effective, safe and inexpensive.
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Affiliation(s)
- Nelson Iván Agudelo Higuita
- Section of Infectious Diseases, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Carrie Yuen
- Section of Hematology and Oncology, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Almalky MA, Saleh SHA, Baz EG, Fakhr AE. Clinico-laboratory profile and perforin gene mutations of pediatric hemophagocytic lymphohistiocytosis cases: a five-year single center study. Pan Afr Med J 2020; 36:354. [PMID: 33224420 PMCID: PMC7664152 DOI: 10.11604/pamj.2020.36.354.25079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction hemophagocytic lymphohistiocytosis (HLH) is an immunological disease characterized by hemophagocytosis of blood cells and proliferation of T-cells and histiocytes in the spleen and bone marrow then infiltration into body organs. Familial HLH (FHL) is a fatal disorder and determining gene mutations is a good guide for predicting the prognosis and choosing treatment options. This study aimed to illustrate the clinical, laboratory characteristics, including perforin gene mutation screening, treatment and survival outcome of pediatric HLH patients. Methods we conducted this cross-sectional study on pediatric patients who were diagnosed with HLH using the revised HLH-2004 criteria, from January 2014 to February 2019 at Zagazig University Children's Hospital, Egypt. We collected demographic, clinical and laboratory data and screened for the presence of mutations in perforin (PRF1) gene by polymerase chain reaction (PCR) amplification. We treated the patients according to HLH-2004 treatment protocol and documented their survival outcome. Results the total number of cases were 18; eight males and ten females, the age range was between three months and 12 years. Of the eight HLH-2004 diagnostic criteria, all patients met at least five criteria. We detected PRF1 gene mutation in 38.9% (7 patients) with nine previously unreported mutations. Sixteen patients (88.9%) received HLH-2004 treatment protocol and the remaining two patients died before initiation of treatment. The overall mortality was 72.2% (13 patients). Conclusion our results increase the awareness of clinical and laboratory characterizations of pediatric HLH patients and the prevalence of PRF1 gene mutations among those patients.
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Affiliation(s)
| | | | - Eman Gamal Baz
- Pediatric Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt
| | - Ahmed Elsadek Fakhr
- Microbiology and Immunology Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt.,Pathology Laboratory and Blood Bank, International Medical Center, Jeddah, Saudi Arabia
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Zhou J, Zhou J, Wu ZQ, Goyal H, Xu HG. A novel prognostic model for adult patients with Hemophagocytic Lymphohistiocytosis. Orphanet J Rare Dis 2020; 15:215. [PMID: 32819431 PMCID: PMC7439554 DOI: 10.1186/s13023-020-01496-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/07/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hemophagocytic Lymphohistiocytosis (HLH) is a type of rare disease with low survival rate. We aimed to develop a model to evaluate the six-month prognosis in adult HLH patients. The data at discharge (will be called as post-treatment) for newly diagnosed adult HLH patients was collected and independent prognostic variables were selected for inclusion in the model. RESULTS Three laboratory markers were confirmed to be the independent risk factors (ferritin: hazard ratio (HR) 0.101, 95% confidence interval (CI) 0.036-0.282, P<0.001; platelets: HR 4.799, 95% CI 1.884-12.223, P = 0.001; alanine aminotransferase (ALT): HR 0.423, 95% CI 0.180-0.997, P = 0.049). These were included in the final clinical prediction model. Receiver operating characteristic (ROC) curves disclosed that this model had a better discrimination (area under the curve (AUC) = 0.842, 95% CI 0.773-0.910, P < 0.001) than each of them alone and the calibration curves aligned completely with the model predictions and actual observations. Kaplan-Meier curves revealed a significant difference in the overall survival (OS) in patients stratified by the model with higher values associated with a better OS. CONCLUSION These results point out that serum ferritin, platelets and ALT levels are independent elements of OS in adult patients with HLH, and that the proposed model have a better prognostic value than any of these markers alone.
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Affiliation(s)
- Jun Zhou
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jing Zhou
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhi-Qi Wu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hemant Goyal
- The Wright Center of Graduate Medical Education, Scranton, USA
| | - Hua-Guo Xu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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111
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Alsaid HM, Wahdan AAM, Tahboub IN, Almakadma NM. Hemophagocytic Lymphohistiocytosis and Relapsing Polychondritis with Acute Myelogenous Leukemia: Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925287. [PMID: 32812531 PMCID: PMC7458697 DOI: 10.12659/ajcr.925287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 16-year-old Final Diagnosis: Hemophagocytic lymphohistiocytosis • relapsing polychondritis Symptoms: Fever • joint pain • leukopenia Medication: — Clinical Procedure: — Specialty: Cardiology • Critical Care Medicine • Hematology • General and Internal Medicine • Pediatrics and Neonatology • Rheumatology
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Affiliation(s)
- Hamza M Alsaid
- Department of Medicine, Hadassah University Hospital, Al-Quds School of Medicine, Jerusalem, Israel
| | - Adnan A M Wahdan
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, West Bank, Palestinian Territory, Occupied
| | - Ihab N Tahboub
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, West Bank, Palestinian Territory, Occupied
| | - Nour M Almakadma
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, West Bank, Palestinian Territory, Occupied
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112
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González-Hernández LA, Alvarez-Zavala M, Cabrera-Silva RI, Martínez-Ayala P, Amador-Lara F, Ramírez-González AS, Ron-Magaña AL, Ruiz Herrera VV, Sánchez-Reyes K, Andrade-Villanueva JF. Cytomegalovirus and disseminated histoplasmosis-related hemophagocytic lymphohistiocytosis syndrome in an HIV-patient late presenter with IRIS: a case report. AIDS Res Ther 2020; 17:52. [PMID: 32795368 PMCID: PMC7427876 DOI: 10.1186/s12981-020-00304-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 07/22/2020] [Indexed: 11/13/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis syndrome (HLS) is an immune-mediated life-threatening disease considered as a medical emergency, with a potentially fatal multisystem inflammatory outcome. We present a patient that developed HLS and was able to be diagnosed efficiently with the help of an academic research institute of immunology. Case presentation A 21 years old male Mexican with human immunodeficiency virus (HIV), late presenter; who developed cytomegalovirus (CMV) infection and a disseminated histoplasmosis-related HLS, as part of an immune reconstitution inflammatory syndrome (IRIS). The patient required a long course of corticotherapy, intravenous immunoglobulin and massive transfusions (more than 10 units in 24 h, and a total of 83 units), besides amphotericin-B and ganciclovir treatment. An academic research institute of immunology aided in the accurate diagnosis of HLS with the implementation of tests not available within the hospital, thus improving the care provided to the patient. The patient recovered, was discharged, and continue to improve. Conclusion The objective of this report is to highlight the importance of having multidisciplinary support, including basic medical sciences groups providing specific tests that are sometimes very difficult to get, which provides a benefit to patients in the well-aimed diagnosis as part of applied translational medicine.
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is characterized by uncontrolled and excessive immune responses with high mortality. We aimed to define mortality-related parameters in HLH secondary to primary immunodeficiency (PID). A total of 28 patients with HLH between the years 2013 and 2017 were enrolled in the study. The patients were evaluated in 2 groups including PID with hypopigmentation (n=7) (Chédiak-Higashi syndrome [CHS] and Griscelli syndrome type 2 [GS2]) and other PIDs (n=21). The median age of the study population was 23 (4.3 to 117.0) months at the time of the diagnosis of HLH. Central nervous system involvement was recorded in 7 (GS2/CHS patients [n=4], other PIDs [n=3], P=0.026), and death was observed in 9 patients (GS2/CHS patients [n=1], other PIDs [n=8], P=0.371). Five patients (3 GS2/CHS and 2 other PID patients) underwent hematopoietic stem cell transplantation. Low serum albumin level was the only variable associated with the mortality and albumin levels less than the cut-off value of 3.07 g/dL increased mortality 5.8 times in patients with HLH secondary to PID. We presented a single-center experience consisting of patients with HLH secondary to PID with a mortality rate of 32.1%. Hypoalbuminemia was the only risk factor to increase the overall mortality rate of HLH.
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114
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Awareness of Hemophagocytic Lymphohistiocytosis as an Unusual Cause of Liver Failure in the Neonatal Period. J Pediatr Hematol Oncol 2020; 42:e479-e482. [PMID: 31567788 DOI: 10.1097/mph.0000000000001600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome that predominantly affects infants from birth to 18 months of age, characterized by fever and multiorgan failure. Liver injury has been rarely reported as a presenting sign in the neonatal period. This study reports a case with HLH in the neonatal period who presented with acute liver failure. CASE PRESENTATION Herein, a 3-day-old female newborn was admitted with cytopenia, increased liver enzymes, hypofibrinogenemia, and markedly elevated serum ferritin. Hemophagocytosis of bone marrow biopsy confirmed the diagnosis of HLH. The newborn was treated with HLH-2004 protocol, but she finally died from multiorgan failure. CONCLUSION Growing awareness of HLH as a cause of liver failure in the neonatal period can be associated with early treatment and reduces mortality in this group of patients.
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Moitinho MS, Belasco AGDS, Barbosa DA, Fonseca CDD. Acute Kidney Injury by SARS-CoV-2 virus in patients with COVID-19: an integrative review. Rev Bras Enferm 2020; 73 Suppl 2:e20200354. [PMID: 32667578 DOI: 10.1590/0034-7167-2020-0354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE to assess scientific evidence on SARS-CoV-2 Acute Kidney Injury in patients with COVID-19. METHODS an integrative review, with adoption of PICO strategy and classification of the level of evidence, carried out on April 10, 2020 in the PubMed database, of articles available between December 2019 and April 2020. RESULTS the sample consisted of six original, five observational and one experimental articles. Observational studies addressed the clinical findings of patients with COVID-19 and association between kidney damage, infection, and morbidity-mortality. CONCLUSION the studies addressed the mechanism of intracellular infection of SARS-CoV-2, its cytopathic effects on kidney cells and incidence of acute kidney injury in patients infected with SARS-CoV-2. Acute kidney injury is associated with increased mortality and morbidity in these patients. This review realizes the need for new research that can mention kidney care to patients with COVID-19.
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Neuroinflammatory Disease as an Isolated Manifestation of Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2020; 40:901-916. [PMID: 32638196 DOI: 10.1007/s10875-020-00814-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/25/2020] [Indexed: 02/07/2023]
Abstract
Isolated neuroinflammatory disease has been described in case reports of familial hemophagocytic lymphohistiocytosis (FHL), but the clinical spectrum of disease manifestations, response to therapy and prognosis remain poorly defined. We combined an international survey with a literature search to identify FHL patients with (i) initial presentation with isolated neurological symptoms; (ii) absence of cytopenia and splenomegaly at presentation; and (iii) systemic HLH features no earlier than 3 months after neurological presentation. Thirty-eight (20 unreported) patients were identified with initial diagnoses including acute demyelinating encephalopathy, leukoencephalopathy, CNS vasculitis, multiple sclerosis, and encephalitis. Median age at presentation was 6.5 years, most commonly with ataxia/gait disturbance (75%) and seizures (53%). Diffuse multifocal white matter changes (79%) and cerebellar involvement (61%) were common MRI findings. CSF cell count and protein were increased in 22/29 and 15/29 patients, respectively. Fourteen patients progressed to systemic inflammatory disease fulfilling HLH-2004 criteria at a mean of 36.9 months after initial neurological presentation. Mutations were detected in PRF1 in 23 patients (61%), RAB27A in 10 (26%), UNC13D in 3 (8%), LYST in 1 (3%), and STXBP2 in 1 (3%) with a mean interval to diagnosis of 28.3 months. Among 19 patients who underwent HSCT, 11 neurologically improved, 4 were stable, one relapsed, and 3 died. Among 14 non-transplanted patients, only 3 improved or had stable disease, one relapsed, and 10 died. Isolated CNS-HLH is a rare and often overlooked cause of inflammatory brain disease. HLH-directed therapy followed by HSCT seems to improve survival and outcome.
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117
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Liu C, Liu N, Wang J, Liu X, Zhang K, Li F. Hemophagocytic Syndrome Caused by Methotrexate Overdose in a Total Knee Arthroplasty Patient: A Case Report. JBJS Case Connect 2020; 10:e20.00068. [PMID: 37475453 DOI: 10.2106/jbjs.cc.20.00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
CASE We report a patient with rheumatoid arthritis (RA) who developed hemophagocytic syndrome (HPS). The HPS was attributed to sepsis, itself a consequence of methotrexate (MTX) overdose. The discovery of MTX overdose was facilitated by the presence of epidermolysis bullosa, multiple ulcers of the whole digestive tract, and additional history from the patient's family. CONCLUSION For arthroplasty patients with underlying inflammatory disorders such as RA, drug history should be thoroughly inquired. Correct diagnosis results from careful history review, detailed physical examination, and necessary laboratory tests.
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Affiliation(s)
- Chen Liu
- Department of Orthopaedics, Peking University International Hospital, Beijing, China
| | - Ning Liu
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Junfeng Wang
- Department of Orthopaedics, Peking University International Hospital, Beijing, China
| | - Xinguang Liu
- Department of Orthopaedics, Peking University International Hospital, Beijing, China
| | - Ke Zhang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Feng Li
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
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[A genetic analysis of children with Epstein-Barr virus-positive hemophagocytic lymphohistiocytosis and its association with T-helper type 1/T-helper type 2 cytokines]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020. [PMID: 32571462 PMCID: PMC7390204 DOI: 10.7499/j.issn.1008-8830.2003184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To study the effect of genetic variation on the prognosis of children with Epstein-Barr virus (EBV)-positive hemophagocytic lymphohistiocytosis (HLH) and its association with cytokines. METHODS A total of 81 EBV-positive HLH children who received the sequencing of related genes were enrolled. According to the results of gene detection, they were divided into a non-mutation group and a mutation group. According to the pattern of gene mutation, the mutation group was further divided into three subgroups: single heterozygous mutation (SHM), double heterozygous mutation (DHM), and homozygous or compound heterozygous mutation (H-CHM). The serum levels of cytokines were measured and their association with HLH gene mutations was analyzed. RESULTS UNC13D gene mutation had the highest frequency (13/46, 28%). The STXBP2 c.575G>A(p.R192H) and UNC13D c.604C>A(p.L202M) mutations (likely pathogenic) were reported for the first time. The mutation group had a significantly higher level of tumor necrosis factor alpha (TNF-α) than the non-mutation group, while it had a significantly lower level of interferon gamma (IFN-γ) than the non-mutation group (P<0.05). The IL-4 level of the DHM subgroup was higher than that of the non-mutation group, while the IL-4 level of the H-CHM subgroup was lower than that of the DHM group (P<0.0083). The H-CHM subgroup had a significantly lower 1-year overall survival rate than the non-mutation group, the SHM subgroup, and the DHM subgroup (39%±15% vs 85%±6%/86%±7%/91%±9%, P=0.001). CONCLUSIONS There is a significant reduction in IFN-γ level in the mutation group. Children with homozygous or compound heterozygous mutation tend to have poorer prognosis, while other mutations do not have a significant impact on prognosis.
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Ren YR, Golding A, Sorbello A, Ji P, Chen J, Saluja B, Witzmann K, Arya V, Reynolds KS, Choi SY, Nikolov NP, Sahajwalla C. A Comprehensive Updated Review on SARS-CoV-2 and COVID-19. J Clin Pharmacol 2020; 60:954-975. [PMID: 32469437 PMCID: PMC7283834 DOI: 10.1002/jcph.1673] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/20/2020] [Indexed: 01/08/2023]
Abstract
This literature review aims to provide a comprehensive current summary of the pathogenesis, clinical features, disease course, host immune responses, and current investigational antiviral and immunomodulatory pharmacotherapies to facilitate the development of future therapies and measures for prevention and control.
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Affiliation(s)
- Yunzhao R Ren
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Amit Golding
- Division of Rheumatology and Transplant Medicine, Office of Immunology and Inflammation, Office of New Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Alfred Sorbello
- Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Ping Ji
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Jianmeng Chen
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Bhawana Saluja
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Kimberly Witzmann
- Office of Bioequivalence, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Vikram Arya
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Kellie S Reynolds
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Su-Young Choi
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Nikolay P Nikolov
- Division of Rheumatology and Transplant Medicine, Office of Immunology and Inflammation, Office of New Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
| | - Chandrahas Sahajwalla
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA
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Suárez-Hormiga L, Jaén-Sánchez MN, Verdugo-Espinosa EA, Carranza-Rodríguez C, Hernández-Cabrera PM, Pisos-Álamo E, Francés-Urmeneta A, Pérez-Arellano JL. Hemophagocytic syndrome in patients infected with the human immunodeficiency virus: A study of 15 consecutive patients. REVISTA ESPANOLA DE QUIMIOTERAPIA 2020; 33:249-257. [PMID: 32560584 PMCID: PMC7374033 DOI: 10.37201/req/037.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives Hemophagocytic syndrome (HPS) is characterized by various clinical and biological data derived from cytokine hyperproduction and cell proliferation. The objectives of this study were to evaluate the epidemiological, etiological, clinical and evolutionary characteristics of patients diagnosed with hemophagocytic syndrome and HIV infection, as well as their comparison with data from the literature. Methods- A retrospective descriptive observational study was performed, including all adult patients with a diagnosis of HPS and HIV infection treated in the Infectious Diseases and Tropical Medicine Unit of the Hospital Universitario Insular, Las Palmas, Gran Canaria from June 1, 1998 to December 31, 2018. Results An analysis of this series of case reports of 15 patients showed a higher percentage of males than females, with a mean age of 42 years. With respect to the diagnostic criteria for HPS, presence of fever, cytopenias and hyperferritinemia were a constant in all patients. Clinical neurological manifestations were frequent and clinical respiratory signs and symptoms absent. HPS was confirmed in some patients who were not severely immune-depressed and had undetectable viral loads. Furthermore, 40% of cases were not receiving ART. The most frequent triggering causes of HPS were viral, especially HHV-8. In addition, two new HPS triggers were identified: Blastocystis dermatitidis and Mycobacterium chelonae. Conclusion Administration of treatment in HPS is arbitrary. This, together with the high mortality rate and the fact that it is underdiagnosed, indicates the importance of conducting future studies.
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Affiliation(s)
| | | | | | - C Carranza-Rodríguez
- Cristina Carranza Rodríguez. Unidad de Enfermedades Infecciosas y Medicina Tropical. Hospital Universitario Insular de Gran Canaria. Av. Marítima del Sur s/n 35016 Las Palmas de Gran Canaria. Spain.
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Allegra A, Pioggia G, Tonacci A, Musolino C, Gangemi S. Cancer and SARS-CoV-2 Infection: Diagnostic and Therapeutic Challenges. Cancers (Basel) 2020; 12:cancers12061581. [PMID: 32549297 PMCID: PMC7352319 DOI: 10.3390/cancers12061581] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 01/08/2023] Open
Abstract
In late December 2019, a new infectious viral disease appeared. A new betacoronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), has been recognized as the pathogen responsible for this infection. Patients affected by tumors are more vulnerable to infection owing to poor health status, concomitant chronic diseases, and immunosuppressive conditions provoked by both the cancer and antitumor therapies. In this review, we have analyzed some lesser known aspects of the relationship between neoplasms and SARS-CoV-2 infection, starting from the different expression of the ACE2 receptor of the virus in the various neoplastic pathologies, and the roles that different cytokine patterns could have in vulnerability to infection and the appearance of complications. This review also reports the rationale for a possible use of drugs commonly employed in neoplastic therapy, such as bevacizumab, ibrutinib, selinexor, thalidomide, carfilzomib, and PD-1 inhibitors, for the treatment of SARS-CoV-2 infection. Finally, we have highlighted some diagnostic challenges in the recognition of SARS-CoV-2 infection in cancer-infected patients. The combination of these two health problems-tumors and a pandemic virus-could become a catastrophe if not correctly handled. Careful and judicious management of cancer patients with SARS-Cov-2 could support a better outcome for these patients during the current pandemic.
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Affiliation(s)
- Alessandro Allegra
- Division of Haematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98125 Messina, Italy;
- COVID Centre AOU Policlinic G. Martino Messina, 98125 Messina, Italy
- Correspondence: ; Tel.: +390902212364
| | - Giovanni Pioggia
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy;
| | - Alessandro Tonacci
- Clinical Physiology Institute, National Research Council of Italy (IFC-CNR), 56124 Pisa, Italy;
| | - Caterina Musolino
- Division of Haematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98125 Messina, Italy;
| | - Sebastiano Gangemi
- School and Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy;
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Treatment outcomes and prognostic factors for non- malignancy associated secondary hemophagocytic lymphohistiocytosis in children. BMC Pediatr 2020; 20:288. [PMID: 32517812 PMCID: PMC7281941 DOI: 10.1186/s12887-020-02178-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/27/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Secondary hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome that requires prompt diagnosis and appropriate treatment. A risk-stratification model that could be used to identify high-risk pediatric patients with HLH who should be considered for second-line therapies, including salvage regimens and allogeneic hematopoietic cell transplantation (HCT), was developed. METHODS The medical records of 88 pediatric patients (median age 1.4 years, range 0.2-15 years) with non-malignancy associated secondary HLH were retrospectively reviewed. Treatment strategies included dexamethasone, etoposide, and cyclosporine. RESULTS Survival analysis showed HLH patients with infections other than Epstein-Barr virus (EBV) and unknown causes experienced better 5-year overall survival (OS) than patients with HLH due to autoimmune disease, EBV or immunodeficiency (76% vs. 65, 33.3, 11%, p < 0.001). On multivariate analysis, among all patients, non-response at 8 weeks was the most powerful predictor of poor OS. When treatment response was excluded, hemoglobin < 60 g/L and albumin < 25 g/L at diagnosis were associated with poor OS. In patients with EBV-HLH, hemoglobin < 60 g/L at diagnosis was associated with poor OS. A prognostic risk score was established and weighted based on hazard ratios calculated for three parameters measured at diagnosis: hemoglobin < 60 g/L (2 points), platelets < 30 × 109/L (1 point), albumin < 25 g/L (2 points). Five-year OS of low-risk (score 0-1), intermediate-risk (score 2), and poor-risk (score ≥ 3) patients were 88, 38, and 22%, respectively (p < 0.001). CONCLUSIONS These findings indicate that clinicians should be aware of predictive factors at diagnosis and consider 8-week treatment response to identify patients with high-risk of disease progression and the need for second-line therapy and allogeneic HCT.
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123
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Han CQ, Xie XR, Zhang Q, Ding Z, Hou XH. Hemophagocytic syndrome as a complication of acute pancreatitis: A case report. World J Clin Cases 2020; 8:2364-2373. [PMID: 32548169 PMCID: PMC7281054 DOI: 10.12998/wjcc.v8.i11.2364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/15/2020] [Accepted: 05/12/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Haemophagocytic syndrome (HPS) is rarely seen in patients with acute pancreatitis (AP). HPS as a complication of AP in patients without any previous history has not been elucidated.
CASE SUMMARY A 46-year-old man was admitted for symptom of persistent abdominal pain, nausea, and vomiting for 2 d after heavy drinking. During hospital stay, he suddenly developed skin rash and a secondary fever. The laboratory findings revealed progressive pancytopenia, abnormal hepatic tests, and elevation of serum triglyceride, ferritin, and lactate dehydrogenase levels. However, apparent bacterial or viral infections were not detected. He was also possibly related to autoimmune diseases because of positive expression of various autoimmune antibodies and no remarkable past history. Finally, the bone marrow examination showed a histiocytic reactive growth and prominent hemophagocytosis, which resulted in a diagnosis of HPS. Unexpectedly, the patient responded well to the immunosuppressive therapy.
CONCLUSION HPS is a very rare extrapancreatic manifestation of AP. The diagnosis relies on bone marrow examination and immunosuppressive therapy is effective. For AP with skin changes, the possibility of HPS should be considered during clinical work.
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Affiliation(s)
- Chao-Qun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xin-Ru Xie
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Qin Zhang
- Division of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xiao-Hua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Hrusak O, Kalina T, Wolf J, Balduzzi A, Provenzi M, Rizzari C, Rives S, Del Pozo Carlavilla M, Alonso MEV, Domínguez-Pinilla N, Bourquin JP, Schmiegelow K, Attarbaschi A, Grillner P, Mellgren K, van der Werff Ten Bosch J, Pieters R, Brozou T, Borkhardt A, Escherich G, Lauten M, Stanulla M, Smith O, Yeoh AEJ, Elitzur S, Vora A, Li CK, Ariffin H, Kolenova A, Dallapozza L, Farah R, Lazic J, Manabe A, Styczynski J, Kovacs G, Ottoffy G, Felice MS, Buldini B, Conter V, Stary J, Schrappe M. Flash survey on severe acute respiratory syndrome coronavirus-2 infections in paediatric patients on anticancer treatment. Eur J Cancer 2020; 132:11-16. [PMID: 32305831 PMCID: PMC7141482 DOI: 10.1016/j.ejca.2020.03.021] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/28/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Since the beginning of COVID-19 pandemic, it is known that the severe course of the disease occurs mostly among the elderly, whereas it is rare among children and young adults. Comorbidities, in particular, diabetes and hypertension, clearly associated with age, besides obesity and smoke, are strongly associated with the need for intensive treatment and a dismal outcome. A weaker immunity of the elderly has been proposed as a possible explanation of this uneven age distribution. Thus, there is concern that children treated for cancer may allso be at risk for an unfavourable course of infection. Along the same line, anecdotal information from Wuhan, China, mentioned a severe course of COVID-19 in a child treated for leukaemia. AIM AND METHODS We made a flash survey on COVID-19 incidence and severity among children on anticancer treatment. Respondents were asked by email to fill in a short Web-based survey. RESULTS We received reports from 25 countries, where approximately 10,000 patients at risk are followed up. At the time of the survey, more than 200 of these children were tested, nine of whom were positive for COVID-19. Eight of the nine cases had asymptomatic to mild disease, and one was just diagnosed with COVID-19. We also discuss preventive measures that are in place or should be taken and treatment options in immunocompromised children with COVID-19. CONCLUSION Thus, even children receiving anticancer chemotherapy may have a mild or asymptomatic course of COVID-19. While we should not underestimate the risk of developing a more severe course of COVID-19 than that observed here, the intensity of preventive measures should not cause delays or obstructions in oncological treatment.
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Affiliation(s)
- Ondrej Hrusak
- CLIP - Childhood Leukaemia Investigation Prague, Czech Republic; Department of Pediatric Hematology, Charles University and Univ. Hospital Motol, Prague, Czech Republic.
| | - Tomas Kalina
- CLIP - Childhood Leukaemia Investigation Prague, Czech Republic; Department of Pediatric Hematology, Charles University and Univ. Hospital Motol, Prague, Czech Republic
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Universita degli Studi di Milano Bicocca, Monza, Italy
| | - Massimo Provenzi
- Oncologia Pediatrica, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Carmelo Rizzari
- Pediatric Hematology Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, ASST Monza, Italy
| | | | | | | | | | - Jean-Pierre Bourquin
- Department of Oncology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kjeld Schmiegelow
- Department of Peadiatrics and Adolescent Medicine, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | | | - Karin Mellgren
- Department of Pediatric Haematology and Oncology, Sahlgrenska University Hospital, Gothenberg, Sweden
| | | | - Rob Pieters
- Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Triantafyllia Brozou
- Department of Pediatric Oncology Hematology and Clinical Immunology Heinrich Heine University Dusseldorf
| | - Arndt Borkhardt
- Department of Pediatric Oncology Hematology and Clinical Immunology Heinrich Heine University Dusseldorf
| | - Gabriele Escherich
- Klinik für Pädiatrische Hämatologie und Onkologie Universtitätsklinikum Eppendorf, Hamburg, Germany
| | - Melchior Lauten
- University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Martin Stanulla
- Department of Pediatric Haematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Owen Smith
- National Children's Cancer Service, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Allen E J Yeoh
- Yong Loo Lin School of Medicine and Cancer Science Institute, National University of Singapore, and Viva-University Children's Cancer Centre, National University Hospital, Singapore
| | | | - Ajay Vora
- Great Ormond Street Hospital, London, UK
| | - Chi-Kong Li
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - Hany Ariffin
- University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Alexandra Kolenova
- Department of Pediatric Hematology and Oncology, Comenius University, Bratislava, Slovakia
| | - Luciano Dallapozza
- The Cancer Centre for Children, The Children's Hospital at Westmead, Australia
| | | | - Jelena Lazic
- University Children`s Hospital, Belgrade, Serbia
| | | | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Gabor Kovacs
- 2nd Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Gabor Ottoffy
- Oncohematology Unit, Dep. of Ped., University of Pécs, Hungary
| | - Maria S Felice
- Hospital de Pediatría, "Prof. Dr. Juan P. Garrahan", Argentina
| | - Barbara Buldini
- Onco Hematology Unit, Dept. Salute della Donna e del Bambino, Università degli Studi di Padova, Italy
| | - Valentino Conter
- Clinica Pediatrica Universita degli Studi di Milano Bicocca, Monza, Italy
| | - Jan Stary
- Department of Pediatric Hematology, Charles University and Univ. Hospital Motol, Prague, Czech Republic
| | - Martin Schrappe
- Childrens Hospital Medical Center Schleswig-Holstein, Kiel, Germany
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Macrophage activation syndrome in adult dermatomyositis: a case-based review. Rheumatol Int 2020; 40:1151-1162. [PMID: 32356114 DOI: 10.1007/s00296-020-04590-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/18/2020] [Indexed: 12/22/2022]
Abstract
Macrophage activation syndrome (MAS) is a severe and life-threatening syndrome associated with autoimmune diseases, characterized by fever, hepatosplenomegaly, and pancytopenia. Dermatomyositis (DM) is one of the causes of MAS; however, its clinical characteristics in DM patients remain unclear. This study aimed to present a case of anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive DM complicated by MAS in a 29-year-old woman and to review the literatures including similar cases. Even though symptoms and cytopenia of our patient were refractory to combination therapy, including glucocorticoids, immunosuppressants, and plasma exchange, the administration of rituximab (RTX) resulted in rapid clinical improvement and glucocorticoid reduction. The literature review revealed 18 adult patients with DM associated MAS. Most patients developed MAS within 3 months from DM onset. A monotherapy of glucocorticoid was insufficient to control the disease, and the mortality of MAS in DM was higher than that of MAS in other rheumatic diseases, despite being treated by various means. RTX may be an effective treatment for patients with DM complicated by MAS who are refractory to conventional therapy. Anti-MDA5 antibody could influence the development of MAS; however, further investigations are needed to elucidate the association between myositis-specific antibody and MAS.
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Laderian B, Koehn K, Holman C, Lyckholm L, Furqan M. Association of Hemophagocytic Lymphohistiocytosis and Programmed Death 1 Checkpoint Inhibitors. J Thorac Oncol 2020; 14:e77-e78. [PMID: 30922584 DOI: 10.1016/j.jtho.2018.11.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Behnam Laderian
- Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Kelly Koehn
- Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Carol Holman
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Laurel Lyckholm
- Division of Hematology, Oncology, Blood and Marrow Transplantation, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Muhammad Furqan
- Division of Hematology, Oncology, Blood and Marrow Transplantation, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
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Hrusak O, Kalina T, Wolf J, Balduzzi A, Provenzi M, Rizzari C, Rives S, Del Pozo Carlavilla M, Alonso MEV, Domínguez-Pinilla N, Bourquin JP, Schmiegelow K, Attarbaschi A, Grillner P, Mellgren K, van der Werff Ten Bosch J, Pieters R, Brozou T, Borkhardt A, Escherich G, Lauten M, Stanulla M, Smith O, Yeoh AEJ, Elitzur S, Vora A, Li CK, Ariffin H, Kolenova A, Dallapozza L, Farah R, Lazic J, Manabe A, Styczynski J, Kovacs G, Ottoffy G, Felice MS, Buldini B, Conter V, Stary J, Schrappe M. Flash survey on severe acute respiratory syndrome coronavirus-2 infections in paediatric patients on anticancer treatment. EUROPEAN JOURNAL OF CANCER (OXFORD, ENGLAND : 1990) 2020. [PMID: 32305831 DOI: 10.16/j.ejca.2020.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Since the beginning of COVID-19 pandemic, it is known that the severe course of the disease occurs mostly among the elderly, whereas it is rare among children and young adults. Comorbidities, in particular, diabetes and hypertension, clearly associated with age, besides obesity and smoke, are strongly associated with the need for intensive treatment and a dismal outcome. A weaker immunity of the elderly has been proposed as a possible explanation of this uneven age distribution. Thus, there is concern that children treated for cancer may allso be at risk for an unfavourable course of infection. Along the same line, anecdotal information from Wuhan, China, mentioned a severe course of COVID-19 in a child treated for leukaemia. AIM AND METHODS We made a flash survey on COVID-19 incidence and severity among children on anticancer treatment. Respondents were asked by email to fill in a short Web-based survey. RESULTS We received reports from 25 countries, where approximately 10,000 patients at risk are followed up. At the time of the survey, more than 200 of these children were tested, nine of whom were positive for COVID-19. Eight of the nine cases had asymptomatic to mild disease, and one was just diagnosed with COVID-19. We also discuss preventive measures that are in place or should be taken and treatment options in immunocompromised children with COVID-19. CONCLUSION Thus, even children receiving anticancer chemotherapy may have a mild or asymptomatic course of COVID-19. While we should not underestimate the risk of developing a more severe course of COVID-19 than that observed here, the intensity of preventive measures should not cause delays or obstructions in oncological treatment.
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Affiliation(s)
- Ondrej Hrusak
- CLIP - Childhood Leukaemia Investigation Prague, Czech Republic; Department of Pediatric Hematology, Charles University and Univ. Hospital Motol, Prague, Czech Republic.
| | - Tomas Kalina
- CLIP - Childhood Leukaemia Investigation Prague, Czech Republic; Department of Pediatric Hematology, Charles University and Univ. Hospital Motol, Prague, Czech Republic
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Universita degli Studi di Milano Bicocca, Monza, Italy
| | - Massimo Provenzi
- Oncologia Pediatrica, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Carmelo Rizzari
- Pediatric Hematology Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, ASST Monza, Italy
| | | | | | | | | | - Jean-Pierre Bourquin
- Department of Oncology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kjeld Schmiegelow
- Department of Peadiatrics and Adolescent Medicine, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | | | - Karin Mellgren
- Department of Pediatric Haematology and Oncology, Sahlgrenska University Hospital, Gothenberg, Sweden
| | | | - Rob Pieters
- Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Triantafyllia Brozou
- Department of Pediatric Oncology Hematology and Clinical Immunology Heinrich Heine University Dusseldorf
| | - Arndt Borkhardt
- Department of Pediatric Oncology Hematology and Clinical Immunology Heinrich Heine University Dusseldorf
| | - Gabriele Escherich
- Klinik für Pädiatrische Hämatologie und Onkologie Universtitätsklinikum Eppendorf, Hamburg, Germany
| | - Melchior Lauten
- University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Martin Stanulla
- Department of Pediatric Haematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Owen Smith
- National Children's Cancer Service, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Allen E J Yeoh
- Yong Loo Lin School of Medicine and Cancer Science Institute, National University of Singapore, and Viva-University Children's Cancer Centre, National University Hospital, Singapore
| | | | - Ajay Vora
- Great Ormond Street Hospital, London, UK
| | - Chi-Kong Li
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - Hany Ariffin
- University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Alexandra Kolenova
- Department of Pediatric Hematology and Oncology, Comenius University, Bratislava, Slovakia
| | - Luciano Dallapozza
- The Cancer Centre for Children, The Children's Hospital at Westmead, Australia
| | | | - Jelena Lazic
- University Children`s Hospital, Belgrade, Serbia
| | | | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Gabor Kovacs
- 2nd Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Gabor Ottoffy
- Oncohematology Unit, Dep. of Ped., University of Pécs, Hungary
| | - Maria S Felice
- Hospital de Pediatría, "Prof. Dr. Juan P. Garrahan", Argentina
| | - Barbara Buldini
- Onco Hematology Unit, Dept. Salute della Donna e del Bambino, Università degli Studi di Padova, Italy
| | - Valentino Conter
- Clinica Pediatrica Universita degli Studi di Milano Bicocca, Monza, Italy
| | - Jan Stary
- Department of Pediatric Hematology, Charles University and Univ. Hospital Motol, Prague, Czech Republic
| | - Martin Schrappe
- Childrens Hospital Medical Center Schleswig-Holstein, Kiel, Germany
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Contreras-Chavez P, Anampa-Guzmán A, Gaznabi S, Lansigan F. Epstein-Barr Virus Infection-associated Hemophagocytic Lymphohistiocytosis. Cureus 2020; 12:e7563. [PMID: 32382465 PMCID: PMC7202582 DOI: 10.7759/cureus.7563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome characterized by uncontrolled immune activation. There is an aberrant activation of lym-phocytes and macrophages that results in hypercytokinemia. We aim to describe a case of secondary HLH due to primary Epstein-Barr virus (EBV) infection. A Hispanic 28-year-old man presented with sore throat and fatigue for one week. He was diagnosed with mononucleosis and discharged and was treated according to the currently available treatment. HLH is treated by diminishing the inflammation by myelosuppressive and immunosuppressive therapy. EBV infection-associated HLH is a rare disease with high mortality. It is crucial to think about it when facing a patient with fever, cytopenia, hepatosplenomegaly, and high levels of ferritin. Despite medical treatment, the patient died from multiorgan failure.
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Affiliation(s)
| | | | - Safwan Gaznabi
- Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, USA
| | - Frederick Lansigan
- Hematology, Dartmouth-Hitchcock Norris Cotton Cancer Center, Lebanon, USA
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129
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Gao WB, Shi MJ, Song XJ, Yang J, Zhu JH. [Clinical analysis of 81 adult patients with hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:248-250. [PMID: 32311896 PMCID: PMC7357923 DOI: 10.3760/cma.j.issn.0253-2727.2020.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Indexed: 12/15/2022]
Affiliation(s)
- W B Gao
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
| | - M J Shi
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
| | - X J Song
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
| | - J Yang
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
| | - J H Zhu
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
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130
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Ramanan KM, Uppuluri R, Ravichandran N, Patel S, Swaminathan VV, Jayakumar I, Raj R. Successful remission induction in refractory familial hemophagocytic lymphohistiocytosis with ruxolitinib as a bridge to hematopoietic stem cell transplantation. Pediatr Blood Cancer 2020; 67:e28071. [PMID: 31762142 DOI: 10.1002/pbc.28071] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/16/2019] [Accepted: 10/21/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Kesavan Melarcode Ramanan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Cancer Institutes, Teynampet, 600035, Chennai, India
| | - Ramya Uppuluri
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Cancer Institutes, Teynampet, 600035, Chennai, India
| | - Nikila Ravichandran
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Cancer Institutes, Teynampet, 600035, Chennai, India
| | - Shivani Patel
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Cancer Institutes, Teynampet, 600035, Chennai, India
| | | | - Indira Jayakumar
- Department of Pediatric Critical Care, Apollo Cancer Institutes, Teynampet, 600035, Chennai, India
| | - Revathi Raj
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Cancer Institutes, Teynampet, 600035, Chennai, India
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Pircher A, Koeck S, Schatzlmayr J, Finkenstedt A, Nairz M, Wanner D, Griesmacher A, Tilg H, Wolf D, Zoller H. Cloak and dagger - secondary hemophygocytic lymphohistiocytosis caused by intravenous autoinfection. Am J Hematol 2020; 95:330-332. [PMID: 31849105 PMCID: PMC7028013 DOI: 10.1002/ajh.25704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/10/2019] [Accepted: 12/12/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Andreas Pircher
- Department of Internal Medicine VMedical University of Innsbruck Innsbruck Austria
| | - Stefan Koeck
- Department of Internal Medicine VMedical University of Innsbruck Innsbruck Austria
| | - Johannes Schatzlmayr
- Department of Internal Medicine VMedical University of Innsbruck Innsbruck Austria
| | - Armin Finkenstedt
- Department of Internal Medicine IMedical University of Innsbruck Innsbruck Austria
| | - Manfred Nairz
- Department of Internal Medicine IIMedical University of Innsbruck Innsbruck Austria
| | - David Wanner
- Department of Internal Medicine VMedical University of Innsbruck Innsbruck Austria
| | - Andrea Griesmacher
- Central Institute of Medical and Chemical Laboratory DiagnosticsUniversity Hospital of Innsbruck Innsbruck Austria
| | - Herbert Tilg
- Department of Internal Medicine IMedical University of Innsbruck Innsbruck Austria
| | - Dominik Wolf
- Department of Internal Medicine VMedical University of Innsbruck Innsbruck Austria
| | - Heinz Zoller
- Department of Internal Medicine IMedical University of Innsbruck Innsbruck Austria
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Hemophagocytic lymphohistiocytosis in adults: collaborative analysis of 137 cases of a nationwide German registry. J Cancer Res Clin Oncol 2020; 146:1065-1077. [PMID: 32076823 PMCID: PMC7085479 DOI: 10.1007/s00432-020-03139-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/29/2020] [Indexed: 01/05/2023]
Abstract
Purpose Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome emerging from a deregulated immune response due to various triggers. In adults, systematic data are sparse, which is why recommendations on diagnosis and management have been adopted from pediatric guidelines. A nationwide clinical registry with associated consulting service as collaborative initiative of HLH-specialized pediatricians and hematologists was initiated to better characterize HLH in adults. Methods Patients with proven or suspected HLH were registered by 44 institutions. Both HLH-2004 diagnostic criteria and the HScore (www.saintantoine.aphp.fr/score/) were used to confirm HLH diagnosis. Data referring to underlying disease, treatment, outcome, clinical presentation and laboratory findings were recorded. Results The study included 137 patients and provides the first systematic data on adult HLH in Germany. Median age was 50 years with a wide range (17–87 years), 87 patients (63.5%) were male. Most common triggering diseases were infections in 61 patients (44.5%) and malignancies in 48 patients (35%). Virtually all patients had elevated ferritin concentrations, and 74% had peak concentrations greater than 10,000 µg/l. At time of analysis, 67 of 131 patients (51%) had died. Patients with malignancy-associated HLH had the shortest median survival (160 days), however no statistically significant difference between subgroups was observed (p = 0.077). Platelets under 20*109/l and low albumin concentrations (< 20 g/l) were associated with poor overall and 30-day survival. Conclusion Close multidisciplinary case consultation and cooperation is mandatory when treating adult HLH patients. Early contact with reference centers is recommended, especially in relapsing or refractory disease. Supplementary Information The online version contains supplementary material available at 10.1007/s00432-020-03139-4.
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133
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Cheng WY, Xu J, Duan LM, Tian T, Wang JJ, Gao X, Yin GL, Huang JY, Wang MM, Liu LL, Qiu HX. [Clinical significance of secondary hemophagocytic lymphohistiocytosis with pleural effusion]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 40:1040-1043. [PMID: 32023738 PMCID: PMC7342671 DOI: 10.3760/cma.j.issn.0253-2727.2019.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- W Y Cheng
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - J Xu
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - L M Duan
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - T Tian
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - J J Wang
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - X Gao
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - G L Yin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - J Y Huang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - M M Wang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - L L Liu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - H X Qiu
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
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134
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Zou LX, Zhu Y, Sun L, Ma HH, Yang SR, Zeng HS, Xiao JH, Yu HG, Guo L, Xu YP, Lu MP. Clinical and laboratory features, treatment, and outcomes of macrophage activation syndrome in 80 children: a multi-center study in China. World J Pediatr 2020; 16:89-98. [PMID: 31612427 DOI: 10.1007/s12519-019-00256-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a major cause of morbidity and mortality in pediatric rheumatology. We aimed to further understand the clinical features, treatment, and outcome of MAS in China. METHODS A multi-center cohort study was performed in seven hospitals in China from 2012 to 2018. Eighty patients with MAS were enrolled, including 53 cases with systemic juvenile idiopathic arthritis (SJIA-MAS), 10 cases of Kawasaki disease (KD-MAS), and 17 cases of connective tissue disease (CTD-MAS). The clinical and laboratory data were collected before (pre-), at onset, and during full-blown stages of MAS. We compared the data among the SJIA-MAS, KD-MAS, and CTD-MAS subjects. RESULTS 51.2% of patients developed MAS when the underlying disease was first diagnosed. In patients with SJIA, 22.6% (12/53) were found to have hypotension before the onset of SJIA-MAS. These patients were also found to have significantly increased aspartate aminotransferase (AST) and lactate dehydrogenase (LDH), as well as decreased albumin (P < 0.05), but no difference in alanine aminotransferase, ferritin, and ratio of ferritin/erythrocyte sedimentation rate (ESR) at onset of MAS when compared to pre-MAS stages of the disease. In addition, ferritin and ratio of ferritin/ESR were significantly elevated in patients at full-blown stages of SJIA-MAS compared to pre-MAS stage. Significantly increased ferritin and ratio of ferritin/ESR were also observed in patients with SJIA compared to in KD and CTD. Receiver-operating characteristic analysis showed that 12,217.5 μg/L of ferritin and 267.5 of ferritin/ESR ratio had sensitivity (80.0% and 90.5%) and specificity (88.2% and 86.7%), respectively, for predicting full-blown SJIA-MAS. The majority of the patients received corticosteroids (79/80), while biologic agents were used in 12.5% (10/80) of cases. Tocilizumab was the most commonly selected biologic agent. The overall mortality rate was 7.5%. CONCLUSIONS About half of MAS occurred when the underlying autoimmune diseases (SJIA, KD, and CTD) were first diagnosed. Hypotension could be an important manifestation before MAS diagnosis. Decreased albumin and increased AST, LDH, ferritin, and ratio of ferritin/ESR could predict the onset or full blown of MAS in patient with SJIA.
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Affiliation(s)
- Li-Xia Zou
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, 57 Zhugan Lane, Hangzhou, 310003, China
| | - Yun Zhu
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, 215003, China
| | - Li Sun
- Department of Rheumatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Hui-Hui Ma
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Si-Rui Yang
- Department of Pediatric Rheumatology and Allergy, The First Hospital of Jilin University, 71 Xinming Street, Changchun, 130021, China
| | - Hua-Song Zeng
- Pediatric Allergy, Immunology and Rheumatology Department, Guangzhou Children's Hospital, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 318 Renminzhong Road, Guangzhou, 510120, China
| | - Ji-Hong Xiao
- Department of Pediatric, The First Affiliated Hospital of Xiamen University, 55 Zhenhai Road, Xiamen, 361003, China
| | - Hai-Guo Yu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Li Guo
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, 57 Zhugan Lane, Hangzhou, 310003, China
| | - Yi-Ping Xu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, 57 Zhugan Lane, Hangzhou, 310003, China
| | - Mei-Ping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, 57 Zhugan Lane, Hangzhou, 310003, China.
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135
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Viñas-Giménez L, Padilla N, Batlle-Masó L, Casals F, Rivière JG, Martínez-Gallo M, de la Cruz X, Colobran R. FHLdb: A Comprehensive Database on the Molecular Basis of Familial Hemophagocytic Lymphohistiocytosis. Front Immunol 2020; 11:107. [PMID: 32076423 PMCID: PMC7006814 DOI: 10.3389/fimmu.2020.00107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/15/2020] [Indexed: 12/26/2022] Open
Abstract
Background: Primary immunodeficiencies (PIDs) are a heterogeneous group of disorders. The lack of comprehensive disease-specific mutation databases may hinder or delay classification of the genetic variants found in samples from these patients. This is especially true for familial hemophagocytic lymphohistiocytosis (FHL), a life-threatening PID classically considered an autosomal recessive condition, but with increasingly demonstrated genetic heterogeneity. Objective: The aim of this study was to build an open-access repository to collect detailed information on the known genetic variants reported in FHL. Methods: We manually reviewed more than 120 articles to identify all reported variants related to FHL. We retrieved relevant information about the allelic status, the number of patients with the same variant, and whether functional assays were done. We stored all the data retrieved in a PostgreSQL database and then built a website on top of it, using the Django framework. Results: The database designed (FHLdb) (https://www.biotoclin.org/FHLdb) contains comprehensive information on reported variants in the 4 genes related to FHL (PRF1, UNC13D, STXBP2, STX11). It comprises 240 missense, 69 frameshift, 51 nonsense, 51 splicing, 10 in-frame indel, 7 deep intronic, and 5 large rearrangement variants together with their allelic status, carrier(s) information, and functional evidence. All genetic variants have been classified as pathogenic, likely pathogenic, uncertain significance, likely benign or benign, according to the American College of Medical Genetics guidelines. Additionally, it integrates information from other relevant databases: clinical evidence from ClinVar and UniProt, population allele frequency from ExAC and gnomAD, and pathogenicity predictions from well-recognized tools (e.g., PolyPhen-2, SIFT). Finally, a diagram depicts the location of the variant relative to the gene exon and protein domain structures. Conclusion: FHLdb includes a broad range of data on the reported genetic variants in familial HLH genes. It is a free-access and easy-to-use resource that will facilitate the interpretation of molecular results of FHL patients, and it illustrates the potential value of disease-specific databases for other PIDs.
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Affiliation(s)
- Laura Viñas-Giménez
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Vall d'Hebron Research Institute (VHIR), Department of Cell Biology, Physiology and Immunology, Autonomous University of Barcelona (UAB), Barcelona, Spain.,Jeffrey Model Foundation Excellence Center, Barcelona, Spain
| | - Natàlia Padilla
- Research Unit in Clinical and Translational Bioinformatics, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Laura Batlle-Masó
- Servei de Genòmica, Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain.,Departament de Ciències Experimentals i de la Salut, Institute of Evolutionary Biology (UPF-CSIC), Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain
| | - Ferran Casals
- Servei de Genòmica, Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain
| | - Jacques G Rivière
- Pediatric Infectious Diseases and Immunodeficiencies Unit (UPIIP), Hospital Universitari Vall d'Hebron (HUVH), Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Jeffrey Model Foundation Excellence Center, Barcelona, Spain
| | - Mónica Martínez-Gallo
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Vall d'Hebron Research Institute (VHIR), Department of Cell Biology, Physiology and Immunology, Autonomous University of Barcelona (UAB), Barcelona, Spain.,Jeffrey Model Foundation Excellence Center, Barcelona, Spain
| | - Xavier de la Cruz
- Research Unit in Clinical and Translational Bioinformatics, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Institut Catala per la Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Roger Colobran
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Vall d'Hebron Research Institute (VHIR), Department of Cell Biology, Physiology and Immunology, Autonomous University of Barcelona (UAB), Barcelona, Spain.,Jeffrey Model Foundation Excellence Center, Barcelona, Spain.,Genetics Department, Hospital Universitari Vall d'Hebron (HUVH), Barcelona, Spain
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136
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Xu L, Zhang X, Lu YJ, Zheng YH, Gao GX. Pulmonary Lymphomatoid Granulomatosis With Hemophagocytic Lymphohistiocytosis as the Initial Manifestation. Front Oncol 2020; 10:34. [PMID: 32064234 PMCID: PMC7000656 DOI: 10.3389/fonc.2020.00034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/09/2020] [Indexed: 12/17/2022] Open
Abstract
Lymphomatoid granulomatosis (LYG) is an extremely rare angio-centric and angio-destructive B-cell lymphoproliferative disease. Driven by Epstein-Barr virus (EBV), LYG predominantly involves the bilateral lungs. Commonly presenting as multiple nodules in the lung, pulmonary LYG can masquerade as various infectious diseases, vasculitis, lung cancer, or other metastatic neoplasm. It is difficult to be diagnosed and is always neglected by clinicians. No standardized therapeutic regimens for LYG has been established yet now. Hemophagocytic lymphohistiocytosis (HLH), a life-threatening condition caused by abnormal activation of macrophages and T-cells, is characterized by fever, hepatosplenomegaly, pancytopenia, hypercytokinemia, and the presence of hemophagocytosis within the bone marrow, liver, spleen, or other lymphatic tissue. We herein report a 55-year-old man with recurrent fever, severe jaundice, and multiple high-density opacities and nodules in both lungs, who was finally diagnosed with pulmonary LYG (Grade 3) manifested with secondary HLH. Administration of HLH-1994 protocol led to the rapid control of the symptoms caused by HLH. Rituximab-based combination therapy was useful yet LYG (Grade 3) progressed rapidly. This case demonstrates that tissue biopsy is essential for early pathological diagnosis and effective treatment of LYG.
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Affiliation(s)
- Li Xu
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xuan Zhang
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ying-Juan Lu
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yan-Hua Zheng
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Guang-Xun Gao
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Hemophagocytic lymphohistiocytosis complicating invasive pneumococcal disease: a pediatric case report. BMC Pediatr 2020; 20:15. [PMID: 31931763 PMCID: PMC6956486 DOI: 10.1186/s12887-020-1915-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 01/07/2020] [Indexed: 12/29/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an infrequent but life-threatening disease due to excessive immune activation. Secondary HLH can be triggered by infections, autoimmune diseases, and malignant diseases. Streptococcus pneumoniae is a pathogenic bacterium responsible for invasive pneumococcal disease (IPD) such as meningitis and bacteremia. Although the pneumococcal conjugate vaccine (PCV) has led to reductions in IPD incidence, cases of IPD caused by serotypes not included in PCV are increasing. There are few reports of secondary HLH caused by IPD in previously healthy children. We herein report a rare case of a previously healthy boy with secondary HLH complicating IPD of serotype 23A, which is not included in the pneumococcal 13-valent conjugate vaccine (PCV-13). Case presentation An 11-month-old boy who had received three doses of PCV-13 was hospitalized with prolonged fever, bilateral otitis media, neutropenia and elevated C-reactive protein (CRP) levels. Blood culture on admission revealed S. pneumoniae, leading to a diagnosis of IPD. HLH was diagnosed based on a prolonged fever, neutropenia, anemia, hepatosplenomegaly, hemophagocytosis in the bone marrow, and elevated serum levels of triglycerides, ferritin, and soluble interleukin-2 receptor. He received broad-spectrum antibiotics and intravenous immunoglobulins for IPD and high-dose steroid pulse therapy and cyclosporine A for HLH; thereafter, his fever resolved, and laboratory findings improved. The serotype of the isolated S. pneumoniae was 23A, which is not included in PCV-13. Conclusions It is important to consider secondary HLH as a complication of IPD cases with febrile cytopenia or hepatosplenomegaly, and appropriate treatment for HLH should be started without delay.
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Hauch H, Skrzypek S, Woessmann W, Lehmberg K, Ehl S, Speckmann C, Schneck E, Koerholz D, Jux C, Neuhäuser C. Tuberculosis-Associated HLH in an 8-Month-Old Infant: A Case Report and Review. Front Pediatr 2020; 8:556155. [PMID: 33194891 PMCID: PMC7661936 DOI: 10.3389/fped.2020.556155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/29/2020] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare immunological disease, which can be mistaken for sepsis easily. Among the infectious causes that may trigger secondary HLH, tuberculosis (TBC), a rather rare pathogen nowadays, is typical. To our knowledge, this is the first case report of an infant suffering from TBC-associated HLH-induced acute respiratory failure who was treated successfully using extracorporeal membrane oxygenation. An 8-month-old boy with fever (over the last 8 wk) and pancytopenia was transferred to our institution with acute respiratory failure and for extracorporeal membrane oxygenation therapy. Bone marrow biopsy revealed hemophagocytosis. Immunological work-up for familial HLH was negative. In a desperate search for the cause of secondary HLH, an interferon-gamma release assay for TBC returned positive. However, microscopy for acid-fast bacteria as well as polymerase chain reaction for TBC were initially negative. Despite this, the child was treated with tuberculostatic therapy. TBC was finally confirmed. The child remained on extracorporeal membrane oxygenation for 28 d. Further work-up showed typical lesions of disseminated TBC. The mother was identified as the source of TBC. The boy presents with mild sequelae (fine motor skills). In infants with suspected septicemia, TBC should be considered as differential diagnosis even if the results are initially negative.
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Affiliation(s)
- Holger Hauch
- Department of Pediatric Hematology and Oncology, University Children's Hospital of Giessen, Giessen, Germany
| | - Susanne Skrzypek
- Department of Pediatric Cardiology and Intensive Care, University Children's Hospital Giessen, Giessen, Germany
| | - Wilhelm Woessmann
- Division of Pediatric Stem Cell Transplantation, University Children's Hospital Hamburg, UKE, Hamburg, Germany
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation, University Children's Hospital Hamburg, UKE, Hamburg, Germany
| | - Stephan Ehl
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg, Germany.,Center of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Carsten Speckmann
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg, Germany.,Center of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology and Intensive Care Medicine, University Children's Hospital Giessen, Giessen, Germany
| | - Dieter Koerholz
- Department of Pediatric Hematology and Oncology, University Children's Hospital of Giessen, Giessen, Germany
| | - Christian Jux
- Department of Pediatric Cardiology and Intensive Care, University Children's Hospital Giessen, Giessen, Germany
| | - Christoph Neuhäuser
- Department of Pediatric Cardiology and Intensive Care, University Children's Hospital Giessen, Giessen, Germany
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139
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Hyzy RC, McSparron J. Hemophagocytic Lymphohistiocytosis and Other Culture Negative Sepsis-Like Syndromes in the ICU. EVIDENCE-BASED CRITICAL CARE 2020. [PMCID: PMC7120049 DOI: 10.1007/978-3-030-26710-0_79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There are many sepsis-like inflammatory syndromes that may be encountered by critical care practitioners. Clinically, these syndromes may imitate sepsis and are often identified after an extensive, but unrevealing evaluation for infection. In some instances, these syndromes are anticipated complications of advanced therapies for malignancy. It is vitally important to identify these disorders and treat them with specific chemotherapeutic or immunomodulating therapies. This chapter will focus on hemophagocytic lympho-histiocytosis (HLH), a rare disorder of pathologic immune system activation that presents as a sepsis-like illness in the critically ill. While treatment of HLH with chemotherapy and immunosuppression should be guided by an expert hematologist, the diagnosis is often made by the critical care medicine practitioner. We present a case illustrating the challenges of defining this syndrome in a patient with recurrent critical illness, and review the evidence underlying diagnostic and prognostic criteria for this protean syndrome. We also review several of the more common sepsis-like inflammatory syndromes that are encountered in the critical care unit along with their specific treatments.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening condition associated with hyperinflammation and multiple organ dysfunction. It has many causes, symptoms, and outcomes. Early recognition is critical for treatment. Fever, cytopenias, coagulopathy, and hepatosplenomegaly are hallmark findings. Identifying the trigger event is crucial but challenging because of the varied presentations and infrequent provider experience. Diagnostic features include anemia, thrombocytopenia, neutropenia, elevated ferritin, hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis (in bone marrow, spleen, or lymph nodes), low or absent natural killer cells, and elevated soluble interleukin 2 receptor assay. Primary treatment goals are eliminating the underlying trigger and suppressing hyperinflammation with steroids, immunoglobulins, or immunomodulators. Specific treatment includes corticosteroids, etoposide, and antithymocyte globulin followed by hematopoietic stem cell transplantation in patients with refractory or relapsing disease. Prompt immunochemical therapy is essential but often complicated by a high risk of treatment-related morbidity and disease recurrence. Despite these challenges, improvements in diagnostic technology and treatment have enhanced survival.
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Affiliation(s)
- Janice Skinner
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Benedicta Yankey
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Brenda K Shelton
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
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Viñas-Giménez L, Donadeu L, Alsina L, Rincón R, de la Campa EÁ, Esteve-Sole A, Català A, Colobran R, de la Cruz X, Sayós J, Martínez-Gallo M. Molecular analysis of the novel L243R mutation in STXBP2 reveals impairment of degranulation activity. Int J Hematol 2019; 111:440-450. [PMID: 31865540 DOI: 10.1007/s12185-019-02796-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 11/26/2022]
Abstract
The presence of mutations in PRF1, UNC13D, STX11 and STXBP2 genes in homozygosis or compound heterozygosis results in immune deregulation. Most such cases lead to clinical manifestations of haemophagocytic lymphohistiocytosis (HLH). In the present study, we analyzed degranulation and cytotoxicity in a pediatric patient with a late presentation of HLH associated with Epstein-Barr virus infection. Remarkably, the results of the degranulation assay showed reduction of CD107a median fluorescence intensity (MFI) and absent cytotoxicity. Genetic analysis identified compound heterozygous mutations in STXBP2 gene: a previously reported splicing defect in exon 15 (c.1247-1G>C, p.V417LfsX126) and a novel missense mutation in exon 9 (c.728T>G, p.L243R). Transfection experiments of STXBP2-L243R or STXBP2-WT constructs showed an undetectable protein expression of the STXBP2-L243R mutation. The residue L243 is highly preserved evolutionarily; moreover, computational analysis of its structure revealed its participation in the rich network of interactions that stabilizes domains 2 and 3 of the protein. Altogether, we demonstrated by molecular and in silico analysis that the new L243R mutation in STXBP2 plays a pathogenic role that, together with the p.Val417Leufsc mutation, shows the synergistic negative effect of these two mutations on STXBP2 function, leading to a decrease of degranulatory activity in vivo.
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Affiliation(s)
- Laura Viñas-Giménez
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Jeffrey Model Foundation Excellence Center, Barcelona, Catalonia, Spain
| | - Laura Donadeu
- Immune Regulation and Immunotherapy Group, CIBBIM-Nanomedicine, Vall d'Hebron Institut de Recerca, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Laia Alsina
- Functional Unit of Clinical Immunology and Primary Immunodeficiencies, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, University of Barcelona, Pediatric Research Institute Sant Joan de Déu, Barcelona, Spain
| | - Rafael Rincón
- Immune Regulation and Immunotherapy Group, CIBBIM-Nanomedicine, Vall d'Hebron Institut de Recerca, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Elena Álvarez de la Campa
- Research Unit in Translational Bioinformatics in Neurosciences, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ana Esteve-Sole
- Functional Unit of Clinical Immunology and Primary Immunodeficiencies, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, University of Barcelona, Pediatric Research Institute Sant Joan de Déu, Barcelona, Spain
| | - Albert Català
- Hematology Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Roger Colobran
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Jeffrey Model Foundation Excellence Center, Barcelona, Catalonia, Spain
- Diagnostic Immunology Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain
- Department of Cell Biology, Physiology and Immunology, Autonomous University of Barcelona (UAB), Barcelona, Catalonia, Spain
- Genetics Department, Hospital Universitari Vall d'Hebron (HUVH), Barcelona, Catalonia, Spain
| | - Xavier de la Cruz
- Research Unit in Translational Bioinformatics in Neurosciences, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Catala per la Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Joan Sayós
- Immune Regulation and Immunotherapy Group, CIBBIM-Nanomedicine, Vall d'Hebron Institut de Recerca, Universitat Autonoma de Barcelona, Barcelona, Spain.
- Institut de Recerca Vall hebron (VHIR), Immune Regulation and Immunotherapy Group, Edifici Mediterrania, Lab 09, Planta baixa, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Mónica Martínez-Gallo
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Jeffrey Model Foundation Excellence Center, Barcelona, Catalonia, Spain.
- Diagnostic Immunology Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain.
- Department of Cell Biology, Physiology and Immunology, Autonomous University of Barcelona (UAB), Barcelona, Catalonia, Spain.
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Menêses MOSDC, Etchebehere RM, De Araújo MF, Duque ACDR, Rodrigues DBR, Pereira SADL. Hemophagocytic Lymphohistiocytosis in Autopsied Adults: Clinical, Laboratory and Immunohistochemical Evaluation for CD68 and CD57. Case Report and Literature Review. JOURNAL OF HEALTH SCIENCES 2019. [DOI: 10.17921/2447-8938.2019v21n4p422-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
AbstractHemophagocytic lymphohistiocytosis (HLH) is a rare, usually fatal and underdiagnosed autoimmune-activated disease. The present study aimed to perform a macroscopic, histopathological and immunohistochemical evaluation for CD68 and CD57 in organs of autopsied adults with HLH. A total of 604 autopsy reports were analyzed, and all the patients that filled the diagnostic criteria for HLH (n = 2) were selected. These patients were 18 and 37 years old. Were evaluated both clinical and autopsy reports and performed histopathological and immunohistochemical analysis of the liver and spleen. Both patients filled the diagnostic criteria for HLH, as well as presented common signs and symptoms of this disease, such as chills, abdominal pain, diaphoresis, and jaundice. Hemophagocytosis was observed in the spleen, bone marrow, and lymph nodes of the two patients at autopsy. Immunostaining in the liver and spleen of both patients was mainly severe for CD68, and predominantly mild for CD57, indicating a decrease in NKC numbers and an increase in the number of macrophages, respectively. This was the first study to evaluate CD57 and CD68 in autopsies of adults with HLH. Thus, more studies are required, not only to better elucidate the pathogenetic mechanisms involved in the secondary HLH, but also to disseminate the results in the clinical environment, contributing to the early diagnosis and treatment with consequent reduction of mortality rate. Keywords: Autoimmune Diseases. Histiocytosis. Biomarkers. ResumoA Linfohistiocitose Hemofagocítica (HLH) é uma doença autoimune rara, geralmente fatal e subdiagnosticada. Este estudo tem como objetivo realizar avaliação macroscópica, histopatológica e imunohistoquímica para CD68 e CD57 em órgãos de pacientes adultos com HLH submetidos a autópsia. Um total de 604 laudos de autópsias foram analisados e todos os pacientes que preencheram os critérios diagnósticos para HLH (n = 2) foram selecionados. Esses pacientes tinham 18 e 37 anos de idade. Foram analisados tanto os prontuários quanto os laudos de autópsia, bem como foram realizadas análises histopatológicas e imunohistoquímicas do fígado e baço dos pacientes. Ambos preencheram os critérios diagnósticos para HLH e apresentarem sinais e sintomas comuns da doença, como calafrios, dor abdominal, sudorese e icterícia. A hemofagocitose foi observada no baço, medula óssea e linfonodos dos dois pacientes na autópsia. A imunohistoquímica do fígado e do baço de ambos os pacientes demonstrou imunomarcação acentuada para CD68 e predominantemente discreta para CD57, que indicam diminuição do número de NKC e aumento do número de macrófagos, respectivamente. Este foi o primeiro estudo a avaliar o CD57 e CD68 em autópsias de adultos com HLH. Assim, mais estudos são necessários, não apenas para melhor elucidar os mecanismos patogenéticos envolvidos na HLH secundária, mas também para disseminar os resultados no ambiente clínico, contribuindo para o diagnóstico e tratamento precoces com consequente redução da taxa de mortalidade. Palavras-chave: Doenças Autoimunes. Histiocitose. Biomarcadores.
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143
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Prencipe G, Bracaglia C, Caiello I, Pascarella A, Francalanci P, Pardeo M, Meneghel A, Martini G, Rossi MN, Insalaco A, Marucci G, Nobili V, Spada M, Zulian F, De Benedetti F. The interferon-gamma pathway is selectively up-regulated in the liver of patients with secondary hemophagocytic lymphohistiocytosis. PLoS One 2019; 14:e0226043. [PMID: 31846457 PMCID: PMC6917341 DOI: 10.1371/journal.pone.0226043] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/19/2019] [Indexed: 12/24/2022] Open
Abstract
Aim of this study was to investigate the activation of the IFNγ pathway in the affected liver and in the blood of patients with secondary hemophagocytic lymphohistiocytosis (sHLH). To this purpose, the mRNA expression levels of IFNG and IFNγ-inducible genes as well as Tyrosine (701)-phosphorylated signal transducer and activator of transcription 1 (STAT1) protein levels were evaluated in the liver and in peripheral blood mononuclear cells (PBMCs) of three patients with sHLH with predominant liver involvement. The mRNA expression levels of IFNG and IFNγ-inducible genes were markedly higher in patient livers compared to control livers and to one disease control liver. Conversely, slight differences in the expression levels of Type I IFN-inducible genes and other classical inflammatory cytokine genes were found. Further supporting the activation of the IFNγ pathway, higher protein levels of phosphorylated and total STAT1 were detected in patient livers compared to control livers. When the expression of the same genes analysed in liver tissues was evaluated in PBMCs collected from 2 out of 3 patients before the liver biopsy, we found that mRNA levels of IFNγ-inducible genes were markedly increased. Accordingly, high circulating levels of IFNγ-inducible CXCL9 were observed in patients. Altogether, these data demonstrate the selective and marked up-regulation of the IFNγ pathway in the liver tissue and blood of patients with active sHLH. Finally, we show that measurement of circulating CXCL9 levels and evaluation of IFNγ-inducible gene expression levels in PBMCs may represent a new valid tool to better identify patients with suspected HLH with predominant liver involvement.
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Affiliation(s)
- Giusi Prencipe
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- * E-mail:
| | - Claudia Bracaglia
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Ivan Caiello
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonia Pascarella
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Manuela Pardeo
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Giorgia Martini
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Marianna N. Rossi
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giulia Marucci
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Valerio Nobili
- Hepatology Gastroenterology and Nutrition Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Zulian
- Department of Woman and Child Health, University of Padua, Padua, Italy
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Baothman A, Almalki H, Abumelha K, Alshegifi A, Baashar A. Type 5 Familial Hemophagocytic Lymphohistiocytosis in a Seven-year-old Girl Post Second Bone Marrow Transplantation with Failure to Thrive: STXBP2 Novel Mutation. Cureus 2019; 11:e6246. [PMID: 31807395 PMCID: PMC6881083 DOI: 10.7759/cureus.6246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Familial hemophagocytic lymphohistiocytosis (HLH) is a fatal autosomal recessive disorder resulting in an exaggerated and ineffective immune response. Genetic defects in familial HLH can lead to the impaired function of the secretory lysosome-dependent exocytosis pathway. We report an STXBP2 homozygous missense mutation c.1139A>G, p.(Gln380Arg) consistent with a genetic diagnosis of familial hemophagocytic lymphohistiocytosis type 5 associated with chronic diarrhea in a seven-year-old girl. She was diagnosed with HLH and achieved remission by the HLH-2004 protocol and allogeneic matched bone marrow transplantation (BMT) from her sibling. However, six years later, she had a relapse of HLH, which required a second BMT. Ever since then, she continued to have persistent chronic watery diarrhea and failure to thrive. Patients with familial HLH type 5 due to STXBP2 gene mutation can manifest as either with or without chronic diarrhea. This unusual relationship directs toward a specific gene mutation of STXBP2 as the cause of chronic diarrhea in familial HLH. The prevalence of familial HLH in Saudi Arabia is underestimated. Due to the high rate of consanguinity and the local customs of marrying within the same community, clinicians should consider familial HLH as a cause of persistent, unexplained, chronic diarrhea among the pediatric age group.
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Affiliation(s)
- Abdullah Baothman
- Pediatrics, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Hani Almalki
- Internal Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
| | | | - Abobaker Alshegifi
- Internal Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Abdulrahman Baashar
- Internal Medicine: Diabetes and Endocrinology, King Saud bin Abdulaziz University for Health Sciences, Makkah, SAU
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Epstein-Barr virus-associated T- and NK-cell lymphoproliferative diseases: an update and diagnostic approach. Pathology 2019; 52:111-127. [PMID: 31767131 DOI: 10.1016/j.pathol.2019.09.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 11/21/2022]
Abstract
Epstein-Barr virus (EBV)-positive T-cell and natural killer (NK)-cell lymphoproliferative diseases (EBV-TNKLPD) are a group of uncommon disorders characterised by EBV infection of T- and NK-cells. As a group, EBV-TNKLPD are more commonly encountered in Asians and Native Americans from Central and South America compared to Western populations. They encompass a spectrum of entities that range from non-neoplastic lesions such as EBV-associated haemophagocytic lymphohistiocytosis (EBV-HLH) to more chronic conditions with variable outcomes such as chronic active EBV infections (CAEBV) of T- and NK-cell type (cutaneous and systemic forms) and malignant diseases such as systemic EBV-positive T-cell lymphoma of childhood, aggressive NK-cell leukaemia, extranodal NK/T-cell lymphoma, nasal-type, and primary EBV-positive nodal T/NK-cell lymphoma. Due to their rarity, broad clinicopathological spectrum and significant morphological and immunophenotypic overlap, the diagnosis and precise classification of EBV-TNKLPD often pose a challenge to clinicians and pathologists. Correct classification of this group of rare diseases relies heavily on the age of onset, disease presentation, duration of symptoms and cell of origin (T- vs NK-cell lineage). In this review, we provide an update on the clinicopathological and molecular features of the various EBV-TNKLPD entities occurring in non-immunocompromised patients and present a practical algorithmic approach for the general pathologist who is confronted with these disorders in routine clinical practice.
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146
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Vandenhaute J, Avau A, Filtjens J, Malengier-Devlies B, Imbrechts M, Van den Berghe N, Ahmadzadeh K, Mitera T, Boon L, Leclercq G, Wouters C, Matthys P. Regulatory Role for NK Cells in a Mouse Model of Systemic Juvenile Idiopathic Arthritis. THE JOURNAL OF IMMUNOLOGY 2019; 203:3339-3348. [PMID: 31676671 DOI: 10.4049/jimmunol.1900510] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 10/04/2019] [Indexed: 12/14/2022]
Abstract
Mice deficient in IFN-γ (IFN-γ knockout [KO] mice) develop a systemic inflammatory syndrome in response to CFA, in contrast to CFA-challenged wild-type (WT) mice who only develop a mild inflammation. Symptoms in CFA-challenged IFN-γ KO resemble systemic juvenile idiopathic arthritis (sJIA), a childhood immune disorder of unknown cause. Dysregulation of innate immune cells is considered to be important in the disease pathogenesis. In this study, we used this murine model to investigate the role of NK cells in the pathogenesis of sJIA. NK cells of CFA-challenged IFN-γ KO mice displayed an aberrant balance of activating and inhibitory NK cell receptors, lower expression of cytotoxic proteins, and a defective NK cell cytotoxicity. Depletion of NK cells (via anti-IL-2Rβ and anti-Asialo-GM1 Abs) or blockade of the NK cell activating receptor NKG2D in CFA-challenged WT mice resulted in increased severity of systemic inflammation and appearance of sJIA-like symptoms. NK cells of CFA-challenged IFN-γ KO mice and from anti-NKG2D-treated mice showed defective degranulation capacities toward autologous activated immune cells, predominantly monocytes. This is in line with the increased numbers of activated inflammatory monocytes in these mice which was particularly reflected in the expression of CCR2, a chemokine receptor, and in the expression of Rae-1, a ligand for NKG2D. In conclusion, NK cells are defective in a mouse model of sJIA and impede disease development in CFA-challenged WT mice. Our findings point toward a regulatory role for NK cells in CFA-induced systemic inflammation via a NKG2D-dependent control of activated immune cells.
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Affiliation(s)
- Jessica Vandenhaute
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium
| | - Anneleen Avau
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium
| | - Jessica Filtjens
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium
| | - Bert Malengier-Devlies
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium
| | - Maya Imbrechts
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium
| | - Nathalie Van den Berghe
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium
| | - Kourosh Ahmadzadeh
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium
| | - Tania Mitera
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium
| | | | - Georges Leclercq
- Department of Clinical Chemistry, Microbiology and Immunology, Ghent University, 9000 Ghent, Belgium; and
| | - Carine Wouters
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium.,Division of Pediatric Rheumatology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute for Medical Research, Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium;
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147
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Lee H, Kim HS, Lee JM, Park KH, Choi AR, Yoon JH, Ryu H, Oh EJ. Natural Killer Cell Function Tests by Flowcytometry-Based Cytotoxicity and IFN-γ Production for the Diagnosis of Adult Hemophagocytic Lymphohistiocytosis. Int J Mol Sci 2019; 20:ijms20215413. [PMID: 31671661 PMCID: PMC6862274 DOI: 10.3390/ijms20215413] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 01/28/2023] Open
Abstract
Although natural killer (NK) cell function is a hallmark of hemophagocytic lymphohistiocytosis (HLH), there is no standard method or data on its diagnostic value in adults. Thus, we performed a single-center retrospective study of 119 adult patients with suspected HLH. NK cell function was determined using both flowcytometry-based NK-cytotoxicity test (NK-cytotoxicity) and NK cell activity test for interferon-gamma (NKA-IFNγ). NK cell phenotype and serum cytokine levels were also tested. Fifty (42.0%) HLH patients showed significantly reduced NK cell function compared to 69 non-HLH patients by both NK-cytotoxicity and NKA-IFNγ (p < 0.001 and p = 0.020, respectively). Agreement between NK-cytotoxicity and NKA-IFNγ was 88.0% in HLH patients and 58.0% in non-HLH patients. NK-cytotoxicity and NKA-IFNγ assays predicted HLH with sensitivities of 96.0% and 92.0%, respectively. The combination of NKA-IFNγ and ferritin (>10,000 µg/L) was helpful for ruling out HLH, with a specificity of 94.2%. Decreased NK-cytotoxicity was associated with increased soluble IL-2 receptor levels and decreased CD56dim NK cells. Decreased NKA-IFNγ was associated with decreased serum cytokine levels. We suggest that both NK-cytotoxicity and NKA-IFNγ could be used for diagnosis of HLH. Further studies are needed to validate the diagnostic and prognostic value of NK cell function tests.
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Affiliation(s)
- Hyeyoung Lee
- Department of Laboratory Medicine, Catholic Kwandong University International St. Mary's Hospital, Incheon 22711, Korea.
| | - Hoon Seok Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Jong-Mi Lee
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Ki Hyun Park
- Department of Biomedicine & Health Sciences, Graduate School, The Catholic University of Korea, Seoul 06591, Korea.
| | - Ae-Ran Choi
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Hyejin Ryu
- Samkwang Medical Laboratories, Seoul 06742, Korea.
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
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148
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Wu R, Deng X, Hao S, Ma L. Successful treatment of diffuse large B-cell lymphoma with secondary hemophagocytic lymphohistiocytosis by R-CHOP-E regimen: a case report. J Int Med Res 2019; 48:300060519882233. [PMID: 31642356 PMCID: PMC7607752 DOI: 10.1177/0300060519882233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare fatal clinical syndrome characterized by a hyperinflammatory condition caused by aberrantly activated macrophages and cytotoxic T cells, resulting in a cytokine storm and organ impairment. Lymphoma, especially B-cell lymphoma in Japan, is a common trigger of secondary HLH. In China, however, most cases of HLH secondary to lymphoma occur in patients with T-cell/natural killer-cell lymphoma or Hodgkin`s lymphoma; HLH is relatively uncommon in patients with B-cell non-Hodgkin's lymphoma. We herein describe a man with diffuse large B-cell lymphoma (DLBCL) and secondary HLH who was successfully treated by R-CHOP-E chemotherapy. All symptoms resolved and laboratory indications of HLH normalized, and complete remission of the lymphoma was achieved. This rare case highlights not only the possibility of HLH secondary to DLBCL but also the importance of early initiation of R-CHOP-E chemotherapy.
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Affiliation(s)
- Ran Wu
- Department of Hematology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaohui Deng
- Department of Hematology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Siguo Hao
- Department of Hematology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Liyuan Ma
- Department of Hematology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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149
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Tavernier SJ, Athanasopoulos V, Verloo P, Behrens G, Staal J, Bogaert DJ, Naesens L, De Bruyne M, Van Gassen S, Parthoens E, Ellyard J, Cappello J, Morris LX, Van Gorp H, Van Isterdael G, Saeys Y, Lamkanfi M, Schelstraete P, Dehoorne J, Bordon V, Van Coster R, Lambrecht BN, Menten B, Beyaert R, Vinuesa CG, Heissmeyer V, Dullaers M, Haerynck F. A human immune dysregulation syndrome characterized by severe hyperinflammation with a homozygous nonsense Roquin-1 mutation. Nat Commun 2019; 10:4779. [PMID: 31636267 PMCID: PMC6803705 DOI: 10.1038/s41467-019-12704-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 09/24/2019] [Indexed: 12/15/2022] Open
Abstract
Hyperinflammatory syndromes are life-threatening disorders caused by overzealous immune cell activation and cytokine release, often resulting from defects in negative feedback mechanisms. In the quintessential hyperinflammatory syndrome familial hemophagocytic lymphohistiocytosis (HLH), inborn errors of cytotoxicity result in effector cell accumulation, immune dysregulation and, if untreated, tissue damage and death. Here, we describe a human case with a homozygous nonsense R688* RC3H1 mutation suffering from hyperinflammation, presenting as relapsing HLH. RC3H1 encodes Roquin-1, a posttranscriptional repressor of immune-regulatory proteins such as ICOS, OX40 and TNF. Comparing the R688* variant with the murine M199R variant reveals a phenotypic resemblance, both in immune cell activation, hypercytokinemia and disease development. Mechanistically, R688* Roquin-1 fails to localize to P-bodies and interact with the CCR4-NOT deadenylation complex, impeding mRNA decay and dysregulating cytokine production. The results from this unique case suggest that impaired Roquin-1 function provokes hyperinflammation by a failure to quench immune activation. Roquin-1 is a posttranscriptional regulator that controls the expression of many immune-related genes such as ICOS and TNFA. Here, the authors report a homozygous R688* loss of function mutation in Roquin-1 in a patient with syndromic uncontrolled hyperinflammation associated with immune cell activation and hypercytokinemia.
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Affiliation(s)
- S J Tavernier
- Primary Immune Deficiency Research Lab, Department of Internal Medicine and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium.,VIB Center for Inflammation Research, Unit of Molecular Signal Transduction in Inflammation, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - V Athanasopoulos
- Department of Immunology and Infectious Disease and Center for Personalised Immunology (NHMRC Centre for Research Excellence), John Curtin School of Medical Research, Australian National University, Canberra, Australia.,Centre for Personalised Immunology (CACPI), Shanghai Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - P Verloo
- Department of Internal Medicine and Pediatrics, Division of Pediatric Neurology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - G Behrens
- Institute for Immunology, Biomedical Center, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,Research Unit Molecular Immune Regulation, Helmholtz Zentrum München, Munich, Germany
| | - J Staal
- VIB Center for Inflammation Research, Unit of Molecular Signal Transduction in Inflammation, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - D J Bogaert
- Primary Immune Deficiency Research Lab, Department of Internal Medicine and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine and Pediatrics, Division of Pediatric Immunology and Pulmonology, Ghent University Hospital, Ghent, Belgium
| | - L Naesens
- Primary Immune Deficiency Research Lab, Department of Internal Medicine and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - M De Bruyne
- Primary Immune Deficiency Research Lab, Department of Internal Medicine and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium.,Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - S Van Gassen
- VIB Center for Inflammation Research, Unit of Data Mining and Modeling for Biomedicine, Ghent, Belgium.,Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Gent, Belgium
| | - E Parthoens
- VIB Bioimaging Core, VIB Center for Inflammation Research, Ghent, Belgium
| | - J Ellyard
- Department of Immunology and Infectious Disease and Center for Personalised Immunology (NHMRC Centre for Research Excellence), John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - J Cappello
- Department of Immunology and Infectious Disease and Center for Personalised Immunology (NHMRC Centre for Research Excellence), John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - L X Morris
- The Australian Phenomics Facility, John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - H Van Gorp
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent, Belgium
| | - G Van Isterdael
- Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium.,VIB Flow Core, VIB Center for Inflammation Research, Ghent, Belgium
| | - Y Saeys
- VIB Center for Inflammation Research, Unit of Data Mining and Modeling for Biomedicine, Ghent, Belgium.,Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Gent, Belgium
| | - M Lamkanfi
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent, Belgium
| | - P Schelstraete
- Department of Internal Medicine and Pediatrics, Division of Pediatric Immunology and Pulmonology, Ghent University Hospital, Ghent, Belgium
| | - J Dehoorne
- Department of Internal Medicine and Pediatrics, Division of Pediatric Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - V Bordon
- Department of Internal Medicine and Pediatrics, Division of Pediatric Immunology and Pulmonology, Ghent University Hospital, Ghent, Belgium
| | - R Van Coster
- Department of Internal Medicine and Pediatrics, Division of Pediatric Neurology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - B N Lambrecht
- Department of Internal Medicine and Pediatrics, Division of Pulmonology, Ghent University Hospital, Ghent, Belgium.,VIB Center for Inflammation Research, Unit for Immunoregulation and Mucosal Immunology, Ghent, Belgium.,Department of Pulmonary Medicine, ErasmusMC, Rotterdam, The Netherlands
| | - B Menten
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - R Beyaert
- VIB Center for Inflammation Research, Unit of Molecular Signal Transduction in Inflammation, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - C G Vinuesa
- Department of Immunology and Infectious Disease and Center for Personalised Immunology (NHMRC Centre for Research Excellence), John Curtin School of Medical Research, Australian National University, Canberra, Australia.,Centre for Personalised Immunology (CACPI), Shanghai Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - V Heissmeyer
- Institute for Immunology, Biomedical Center, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,Research Unit Molecular Immune Regulation, Helmholtz Zentrum München, Munich, Germany
| | - M Dullaers
- Primary Immune Deficiency Research Lab, Department of Internal Medicine and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium.,Ablynx, a Sanofi Company, Zwijnaarde, Belgium
| | - F Haerynck
- Primary Immune Deficiency Research Lab, Department of Internal Medicine and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium. .,Department of Internal Medicine and Pediatrics, Division of Pediatric Immunology and Pulmonology, Ghent University Hospital, Ghent, Belgium.
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150
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The Conundrum of Septic Shock Imitators in Patients with Hematologic Cancers: Case Presentation and Possible Differential Diagnoses. Case Rep Crit Care 2019; 2019:6561018. [PMID: 31583137 PMCID: PMC6754887 DOI: 10.1155/2019/6561018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/04/2019] [Accepted: 07/15/2019] [Indexed: 11/27/2022] Open
Abstract
The authors describe the case of a patient treated with several cycles of chemotherapy due to an advanced stage non-Hodgkin lymphoma. One daafter the last cycle, he was admitted to our Intensive Care Unit with a septic shock-like clinical picture which didn't respond to the aggressive treatment and the patient died a few hours later. The autoptical findings cast some doubts on the diagnosis, and demonstrated the presence of other factors imitating its symptoms. In this article, the mimickers of septic shock are reviewed and discussed, as some of them require an aggressive immunosuppression instead of the recommended treatment for septic shock.
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